Pressure Ulcer Staging

Which pressure ulcer stage includes exposure of bone, muscle or tendons?

• Stage I

• Stage II

• Stage III

• Stage IV

• Stage IV

Which of the following pressure ulcer stages is considered full thickness?

• Stage I

• Stage II

• Stage III

• Stage IV

• Unstageable

Stage I pressure ulcer includes which of the following?

• full thickness tissue loss

• exposed bone, tendon and/or muscle

• non-blanchable erythema of intact skin

• unstageable

When slough and/or eschar is present, the wound is identified as unstageable when____?

• the base of the wound cannot be determined

• the periwound is blanch able

• you can see tendon, bone and/or muscle

What stage pressure ulcer is identified as full thickness tissue loss, slough and/or eschar may be visible, you cannot identify bone, tendon or muscle. Granulation and epibole may be present.

• Stage I

• Stage II

• Stage III

• Stage IV